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Why People Die By Suicide Thomas Joiner, Ph.D. The Robert O. Lawton Distinguished Professor of Psychology Department of Psychology Florida State University.

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Presentation on theme: "Why People Die By Suicide Thomas Joiner, Ph.D. The Robert O. Lawton Distinguished Professor of Psychology Department of Psychology Florida State University."— Presentation transcript:

1 Why People Die By Suicide Thomas Joiner, Ph.D. The Robert O. Lawton Distinguished Professor of Psychology Department of Psychology Florida State University

2 On February 1, 2003, the space shuttle Columbia disintegrated as it flew over the western United States…

3 … finally showering down over East Texas and Louisiana in thousands of pieces, killing all seven crew members.

4 The cause was a dense, dry, brownish-orange piece of foam weighing about 1.7 pounds, 19 inches long and 11 inches wide. The foam hit Columbia’s left wing traveling 545 mph, causing what investigators now know was a significant breach in the wing.

5 One of the members of the panel investigating the accident said “The excitement that only exists when there is danger was kind of gone – even though the danger was not gone.” Key NASA administrators decided against getting in-flight satellite images of the left wing, in part because their sense of danger about foam strikes has eroded over the years, due to repeated experience with them.

6 Relevance to Suicide A key point of my theory is that when people get used to dangerous behavior – when they lose “the excitement that only exists when there is danger” in the words of the accident investigator – the groundwork for catastrophe is laid down. Just as NASA administrators became inured to a very real danger, to the point of no longer even worrying about foam strikes, so too, I will argue, do potentially suicidal people lose the danger signals and alarm bells that should accompany self-injury.

7 The Acquired Ability for Suicide When self-injury and other dangerous experiences become “unthreatening and mundane” – when people work up to the act of death by suicide by getting used to its threat and danger – that is when we might lose them. That is when they have developed the acquired ability to enact lethal self- injury.

8 A Good Theory  Explains the heretofore unexplained….

9 Why….?  …. do female physicians and prostitutes have high rates of suicide?  …. do suicide rates decrease in times of national crisis and increase when a city’s sports team dashes expectations?  …. have societies across history and across culture sanctioned ritual suicide?

10 Tall Order for a Comprehensive Theory of Suicide  Not only must the theory illuminate these and other questions, it must also be compatible with these facts:

11 Facts  Suicide rates highest in older people  … and in men (except in China)  … and in Caucasian people in the U.S.  Suicide is associated with impulsivity, yet very few die ‘on a whim.’  Suicide is more associated with anorexia than with bulimia.

12 More Facts…  Completed suicide is relatively rare – 80 per day die in U.S., compared to 1,900 per day from heart disease.

13 Serious Attempt or Death by Suicide Those Who Desire Suicide Those Who Are Capable of Suicide Perceived Burdensomeness Thwarted Belongingness Sketch of the Theory

14 The Acquired Capability to Enact Lethal Self-Injury  “It seems rather absurd to say that Cato slew himself through weakness. None but a strong man can surmount the most powerful instinct of nature” – Voltaire.  Accrues with repeated and escalating experiences involving pain and provocation, such as –Past suicidal behavior, but not only that… –Repeated injuries (e.g., childhood physical abuse). –Repeated witnessing of pain, violence, or injury (cf. physicians). –Any repeated exposure to pain and provocation.

15 The Acquired Capability to Enact Lethal Self-Injury: Habituation  Habituation: Response decrement due to repeated stimulation.

16 The Acquired Capability to Enact Lethal Self-Injury  With repeated exposure, one habituates – the “taboo” and prohibited quality of suicidal behavior diminishes, and so may the fear and pain associated with self-harm.  Relatedly, opponent-processes may be involved.

17 The Acquired Capability to Enact Lethal Self-Injury  Briefly, opponent process theory (Solomon, 1980) predicts that, with repetition, the effects of a provocative stimulus diminish…. habituation in other words. BUT….

18 The Acquired Capability to Enact Lethal Self-Injury  Opponent process theory also predicts that, with repetition, the opposite effect, or opponent process, becomes amplified and strengthened.  Example of skydiving.

19 The Acquired Capability to Enact Lethal Self-Injury  The opponent process for suicidal people may be that they become more competent and fearless, and may even experience increasing reinforcement, with repeated practice at suicidal behavior.

20 Why I Jumped by Tina Zahn  In the midst of a recurrent, very severe (at times near-catatonic) postpartum depression, Zahn decided to jump off a bridge near Green Bay, Wisconsin.  She fled relatives in her car, who called police. Police clocked her at 120 mph.  Still, she is ambivalent, some signs of which show up in the following video.

21 The Documentary The Bridge  Photographer saves someone who is pondering jumping from the Golden Gate Bridge.  Here too, behavioral indicators of ambivalence.

22 “Don’t kill your own”: A rule of nature  It’s the 6 th commandment, but piranha and rattlesnakes know it too, as did Civil War soldiers at Vicksburg.

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25 Anecdotal Evidence: Cobain  Cobain was temperamentally fearful – afraid of needles, afraid of heights, and, crucially, afraid of guns. Through repeated exposure, a person initially afraid of needles, heights, and guns later became a daily self-injecting drug user, someone who climbed and dangled from 30 foot scaling during concerts, and someone who enjoyed shooting guns.

26 Anecdotal Evidence: Cobain  Regarding guns, Cobain initially felt that they were barbaric and wanted nothing to do with them; later he agreed to go with his friend to shoot guns but would not get out of the car; on later excursions, he got out of the car but would not touch the guns; and on still later trips, he agreed to let his friend show him how to aim and fire. He died by self-inflicted gunshot wound in 1994 at the age of 27.

27 Anecdotal Evidence: Fire Victim  “I wonder why all the ways I’ve tried to kill myself haven’t worked. I mean, I tried hanging; I used to have a noose tied to my closet pole. I’d go in there and slip the thing over my head and let my weight go, but every time I started to lose consciousness, I’d just stand up. I tried to take pills; I took 20 Advil one afternoon, but that just made me sleepy. And all the times I tried to cut my wrist, I could never cut deep enough. That’s the thing, your body tries to keep you alive no matter what you do (italics added).”

28 Anecdotal Evidence: Meriwether Lewis (of Lewis & Clark fame)  From Stephen Ambrose’s biography of Lewis, Undaunted Courage: –Lewis paced for several hours (agitation), as others could hear him all night as the floorboards creaked. –Two self-inflicted gunshot wounds, neither fatal. –Servants found him “busily cutting himself from head to foot.” –Lewis said to servants, “I am no coward, but I am strong, it is so hard to die.” He died a few hours later.

29 Suicide in Anorexia Nervosa  Mortality is extremely high in anorexic women (SMR = ~60).  It is an under-appreciated fact that, should an anorexic patient die prematurely, the cause of death is more likely to be suicide than complications arising from compromised nutritional status.

30 Suicide in Anorexia Nervosa  There are at least two possible accounts of the high association between AN and suicide. In one view, anorexic women die by suicide at high rates because they are unable to survive relatively low lethality attempts and/or they may be less likely to be rescued after an attempt due to their socially isolated status.

31 Suicide in Anorexia Nervosa  In another view, informed by my theory of suicidal behavior, anorexic women die by suicide at high rates because their histories of self- starvation habituate them to pain and inure them to fear of death, and they therefore make high lethality attempts with high intent-to-die.

32 Suicide in Anorexia Nervosa  We pitted these two accounts against each other, in a study of 239 women with AN, followed over ~15 years.  9 died by suicide, the leading cause of death among the sample.  Of these 9, were they mostly highly lethal methods or not?

33 Suicide in Anorexia Nervosa  The least lethal method: Ingestion of 12 oz. of Lysol toilet bowl cleaner, along with an unknown amount of a powerful sedative and alcohol (BAC = 0.16%). Cause of death was gastric hemorrhaging due to hydrochloric acid in the Lysol.

34 Serious Attempt or Death by Suicide Those Who Desire Suicide Those Who Are Capable of Suicide Perceived Burdensomeness Thwarted Belongingness

35 Constituents of the Desire for Death  Perceived Burdensomeness  Thwarted Belongingness

36 Perceived Burdensomeness  Essential calculation: “My death is worth more than my life to my loved ones/family/society.”

37 Perceived Burdensomeness: Anecdotal Evidence  Among the Yuit Eskimos of St. Lawrence Island, to become too sick, infirm, or old may threaten the group’s survival (i.e., burden the group); the explicit and socially sanctioned solution to this problem is ritual suicide. The ritual is graphic, often involving the family members’ participation in the shooting or hanging of the victim

38 Perceived Burdensomeness: Anecdotal Evidence  Burn victim mentioned earlier: "I felt my mind slip back into the same pattern of thinking I'd had when I was fourteen [when he attempted suicide]. I hate myself. I'm terrible. I'm not good at anything. There's no point in me hanging around here ruining other people's lives. I've got to get out of here. I've got to figure out a way to get out of my life."

39 Perceived Burdensomeness: Self- Sacrifice Across Species  Fire ants.  Pea aphids.  Lions.  Spiders  …. even a palm tree.

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43 Strengthening Belongingness  New CDC vision: Promote connectedness –The degree to which a person or group is socially close, interrelated, or shares resources with other persons or groups Between individuals Between individuals/families and community organizations Among community organizations and social institutions

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46 Serious Attempt or Death by Suicide Those Who Desire Suicide Those Who Are Capable of Suicide Perceived Burdensomeness Thwarted Belongingness

47 Constituents of the Desire for Death  Perceived Burdensomeness  Thwarted Belongingness

48 Thwarted Belongingness: Empirical Evidence  Hoyer and Lund (1993) studied nearly a million women in Norway; over the course of a 15-year follow-up, over 1,000 died by suicide. They reported that women with six or more children had one-fifth the risk of death by suicide as compared to other women. Hoyer, G., & Lund, E. (1993). Suicide among women related to number of children in marriage. Archives of General Psychiatry, 50,

49 Thwarted Belongingness: Empirical Evidence  Twins die by suicide at lower rates than others despite having slightly higher rates of mental disorders. Tomassini et al. (2003). Risk of suicide in twins: 51 year follow up. British Medical Journal, 327,

50 Thwarted Belongingness: Empirical Evidence  The camaraderie and sense of belongingness from being a fan of sports teams can be considerable, especially under conditions of success…

51 Thwarted Belongingness: Empirical Evidence  … as many who have lived in university towns can observe for themselves when the university wins a national championship, say, in football, say in 1993 or 1999.

52 Thwarted Belongingness: Empirical Evidence  It is interesting to consider, then, whether teams’ success affects suicidality; from the present perspective, it might, in that increased belongingness should be associated with lower suicidality.

53 Thwarted Belongingness: Empirical Evidence  Several studies have documented this association. Joiner, T., Van Orden, K., & Hollar, D. (2006). On Buckeyes, Gators, the Miracle on Ice, and Super Bowl Sunday: Pulling Together Is Associated With Lower Suicide Rates. Journal of Social & Clinical Psychology. Fernquist, R.M. (2000). An aggregate analysis of professional sports, suicide, and homicide rates: 30 U.S. metropolitan areas, Aggression & Violent Behavior, 5, Steels, M.D. (1994). Deliberate self poisoning - Nottingham Forest Football Club and F. A. Cup defeat. Irish Journal of Psychological Medicine, 11, Trovato, F. (1998). The Stanley Cup of Hockey and suicide in Quebec, Social Forces, 77,

54 Thwarted Belongingness: Poor Red Sox Fans

55 Thwarted Belongingness: Poor Red Sox Fans (Well, Until 2004 and 2007)

56  Miracle on Ice, February 22, 1980

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60 Serious Attempt or Death by Suicide Those Who Desire Suicide Those Who Are Capable of Suicide Perceived Burdensomeness Thwarted Belongingness DistalFactorsDistalFactors

61 Prevention/Treatment Implications  The model’s logic is that prevention of “acquired ability” OR of “burdensomeness” OR of “thwarted belongingness” will prevent serious suicidality.  Belongingness may be the most malleable and most powerful.

62 Prevention/Treatment Implications  Example PSA: “Keep your old friends and make new ones – it’s powerful medicine.”

63 TALK Suicidepreventionlifeline.org

64 Prevention/Treatment Implications  CBT -> burdensomeness and low belonging.

65 Available at places like amazon.com

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67 Thank you for your attention 

68 Theory-Based Assessment & Treatment of Suicidal Behavior Thomas Joiner, Ph.D. The Bright-Burton Professor Department of Psychology Florida State University

69 Goals  Epidemiology  Risk Factors  Assessment and Diagnosis (including in some special populations)  Therapy foundations  Crisis resolution  Choosing and Implementing treatments

70 Prevalence, Incidence, Morbidity, Mortality Each year in the U.S., approximately 30,000 people die by suicide (about 1 every 17 minutes; about 82 per day). ~10 th leading cause of death. More common than death by homicide. For every completion, there are 25 attempts, for a total of around 750,000 U.S. attempts per year (not individuals but attempts). Approx. 5 million people living in the U.S. have attempted suicide at least once.

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72 Age, Gender, and Ethnicity- Related Issues Overall rate in U.S. is around 10 per 100,000; for people ages 15-24, rate is similar; rate is highest among people 65+, where rate is 17 per 100,000 and this is mostly accounted for by white men (among whom rate is around 37 per 100,000).

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74 Age, Gender, and Ethnicity- Related Issues (continued) Regarding gender, chances of death by suicide are considerably higher in men than in women (overall U.S. rates are 19/100,000 for men, and 5/100,000 for women) – partly a function of tendency toward violent behavior (2 of 3 male suicide victims in U.S. die by firearm; 1 of 3 for women – most common method for female victims is overdose/poisoning).

75 Age, Gender, and Ethnicity- Related Issues (continued) However, chances of attempting suicide are higher in women (about 3 times higher). Women’s attempts are more frequent but less violent; vice-versa for men.

76 Age, Gender, and Ethnicity- Related Issues (continued)

77 Regarding ethnicity, in the U.S. suicide has historically been a “white” problem, but that has changed somewhat recently, mostly owing to an increase in African- American men (rate is now over 10 per 100,000; used to be under 5 per 100,000; for African-American women, rate is around 2 per 100,000 and has not changed much over time).

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79 Suicide Rates * Historically, the suicide rate for African Americans has been much lower than that of most racial/ethnic groups.

80 Suicidal Behavior in Context of Axis I and II Psychopathologies  Disorders that share features of burdensomeness, low belongingness, and acquired ability (fearlessness, resolve re: suicide) are most likely to involve suicidality.

81 Suicidal Behavior in Context of Axis I and II Psychopathologies Mood disorders: Regarding major depression, estimates are ~10% mortality due to suicide - may be particularly true for those with “double depression” (dysthymia + major depression), and for those comorbid for major depression and anxiety disorders. Regarding bipolar disorder, mortality estimates are 10-15% for bipolar I, same for bipolar II.

82 Suicidal Behavior in Context of Axis I and II Psychopathologies Anxiety disorders: Mortality estimates are less clear here (fearfulness is an issue), but there is risk, one source of which is comorbidity with major depression (e.g., GAD and major depression share genetic risk). Anxiety can be very painful and can instill hopelessness.

83 Suicidal Behavior in Context of Axis I and II Psychopathologies Schizophrenia: Mortality estimate is around 10%, in part due to delusional self-hatred, or delusional burdensomeness (Joiner, Gencoz, Gencoz, Metalsky, & Rudd, 2001).

84 Suicidal Behavior in Context of Axis I and II Psychopathologies Schizophrenia (continued): In his classic Dementia Praecox, Bleuler (1911) described the self-concept of schizophrenic patients as often including delusions of inferiority, poverty, and sinfulness. He stated: “The delusions have the same content as depression, except that schizophrenia often tinges them with its own peculiar coloring of contradiction, incompleteness and senselessness” (p. 122).

85 Suicidal Behavior in Context of Axis I and II Psychopathologies Schizophrenia (continued): Bleuler cites an example of a schizophrenic patient who believes that God has withdrawn from him through his belly; a second schizophrenic patient, in explaining a suicide attempt, stated “All the world’s murderers wait for me; they cannot die without me.”

86 Suicidal Behavior in Context of Axis I and II Psychopathologies Substance use disorders: Again, mortality estimate approaches 10%; here, impulsivity is an issue.

87 Suicidal Behavior in Context of Axis I and II Psychopathologies Borderline personality disorder: 10% mortality estimate. At least 50% with at least one severe attempt in the past. Some evidence that past attempt is more predictive of completed suicide in this group vs. other diagnostic group. The unfortunate reputation for manipulation/gesturing can misguide clinicians.

88 Suicidal Behavior in Context of Axis I and II Psychopathologies Antisocial personality disorder: Somewhat elevated risk, but only for a proportion. My colleagues and I recently found that those who impulsively engage in antisocial behaviors are at risk; those who are “Cleckley psychopaths” (e.g., callous, unemotional) are not.

89 Suicidal Behavior in Context of Axis I and II Psychopathologies  These diagnostic issues are key in terms of treatment planning – for someone who is repeatedly suicidal, a therapy that primarily targets suicidality is probably best; whereas, for someone who becomes suicidal for the first time in context of a major depressive episode, a therapy primarily targeting depression may be best (more on this when treatment is discussed).

90 General Risk Factors – a very long list  genetics (one candidate gene is the serotonin transporter gene)  prenatal stress (maternal influenza plays a possible role)  childhood/family factors  sexual orientation (especially among adolescents)  whole class of negative life events  loneliness  hopelessness (Brown/Beck study)

91 General Risk Factors – a very long list (continued)  previous suicidal experience (acquired ability)  emotional pain (termed psycheache by Shneidman), especially about burdensomeness and loneliness  impulsivity  self-hatred (compare to burdensomeness)  many Axis I and II diagnoses

92 Barriers to Risk Assessment  Prodromality  Unaware/Latent Risk  Deceit/Demand Characteristics

93 Distillation of Risk Factors  Talking about/planning suicide (safety planning)  Agitation (benzos)  Insomnia (sleep hygiene)  Nightmares (rescripting)  Marked social withdrawal (list of 300). –Motivational Interviewing

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95 Distillation of Risk Factors  Two others to consider (but less strongly): –Humiliation –Anger (marked increase)

96 Distillation of Risk Factors  What’s not listed? –Sluggishness Hopelessness Depression

97 VIP mnemonic  V is for voluntary hospitalization – mention it.  I is for intensify treatment – more frequent, additional treatments, etc.  P is for phone check-ins.

98 More on Risk Categories  If risk category is Mild-Moderate: possible actions include more frequent sessions, referral for adjunctive treatments (e.g., antidepressant medicines), phone monitoring, incorporation of family members, “coping card” (discussed in a moment), provision of crisis hotline numbers, reminder of emergency contact numbers. Documentation in progress notes of risk category and attendant actions is necessary.

99 More on Risk Categories  If risk category is Severe: actions are similar to those for Mild-Moderate, but “stepped” up (e.g., do most or all of these), and voluntary hospitalization is discussed. Again, documentation in progress notes of risk category and attendant actions is necessary.  If risk category is Extreme: Hospitalization is enacted.  Documentation: Just do it every time.

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102 No Suicide Contracts  What about no suicide contracts? Agreement to follow “coping card” may be better, because it tells people what to do instead of what not to do.  In one study, 41% of clinicians using contracts had patients die by suicide or severely attempt while on contract (Kroll, 2000, Am. J. Psychiat.).

103 Setting the foundation for treatment - Informed consent: confidentiality as balanced by safety; commitment to treatment – revisit as needed using motivational interviewing techniques.

104 Informed Consent “If you’re presenting with some form of suicidality (i.e. suicidal thinking or a suicide attempt), it’s important to recognize the risks inherent in treatment, as well as a decision not to seek treatment. Randomized controlled trials for the treatment of suicidality have found re-attempt rates during treatment as high as 47%, with a number of experimental treatments significantly reducing the rate of subsequent attempts by as much as half. The risk of a suicide attempt during treatment is greatest for those who have made multiple suicide attempts (i.e. two or more)…”

105 Fascinating and Provocative Approach “I tell my patients certain actions are evil - and if you do this - if you kill yourself or someone else - I'm going to come after you and drag you out of hell.” - quoted (anonymously) from an eminent psychiatrist.

106 Fascinating and Provocative Approach “ My patients - to a man and woman - are both astonished that a psychiatrist would make a judgment about good and evil in the present day and are comforted that someone cares enough about them and their life to try to do everything possible to protect and sustain it. The point is usually being made in the midst of therapeutic planning and I back it up with my availability to them during the crisis and its resolution that has prompted their sense of despair. Try it, you'll like it.” - quoted (anonymously) from an eminent psychiatrist.

107 Risk Factors - Summary  The list of risk factors is so long that it can be overwhelming. No real solution to this problem, but best approach is to rely on efficient, objective assessment framework, to be presented later.

108 Very Brief Self-Report Measure  A brief self-report measure (Joiner, Pfaff, & Acres, Behaviour Research & Therapy, 2002). Likely similar to other good scales (e.g., the Beck Suicide Scale), but many of these are costly; this one is free.

109 Very Brief Self-Report Measure  0 I do not have thoughts of killing myself.  1 Sometimes I have thoughts of killing myself.  2 Most of the time I have thoughts of killing myself.  3 I always have thoughts of killing myself.

110 Very Brief Self-Report Measure  0 I am not having thoughts about suicide.  1 I am having thoughts about suicide but have not formulated any plans.  2 I am having thoughts about suicide and am considering possible ways of doing it.  3 I am having thoughts about suicide and have formulated a definite plan.

111 Very Brief Self-Report Measure  A cut-off of 3 or above (for the 4 items summed) seemed a sensible cut-off.

112 Survivor of Suicide Attempt  “After she broke up with me, I started thinking about suicide. That night, I drank 3 or 4 beers and then got together all my medication, and just counted out all the pills. I wrote a note to her and my parents. I took all the pills and just lay down on the couch. I got scared and called my mom. I don’t remember anything after that and the next morning I woke up in the ER.” Clinical Anecdote: Near-Lethal Suicide Attempt

113 Suicide Victim’s Journal Entries  First Entry: I bought a gun the other day. Didn’t buy ammo, but not too far off. Been obsessing about my gun.  Second Entry: I fired my gun today; five rounds. It’s really loud. Been thinking and dreaming about it (suicide).  Third Entry: I really flipped out today; threw my ammo at someone in public; I know I have to do it now; there’s no hope for me.  [person died by self-inflicted gunshot wound 4 days after this last entry]. Clinical Anecdote: Completed Suicide

114 Toward a Risk Assessment Framework  A General Framework for Suicide Risk Assessment (Joiner, Walker, Rudd, & Jobes, 1999) will be presented  Its Goal is to efficiently and objectively categorize with regard to suicide risk.  Specific names of categories are less important than their consistency and their tie to clinical decision-making.  I like these 4 categories: None, mild- moderate, severe, and extreme.

115 Toward a Risk Assessment Framework  Two Most Important Areas: History of Previous Attempt/Fearlessness and Nature of Current Suicidal Symptoms  Regarding History of Previous Attempts, our research shows that people who have a history of 0 or 1 previous attempt are just in a different risk category than people who have 2 or more attempts. Regardless of all the other things going on, this one variable tells you a lot about risk. The multiple attempters are virtually always in a higher risk category than their counterparts with 0 or even 1 previous attempt.

116 Toward a Risk Assessment Framework  Two Most Important Areas: History of Previous Attempt/Fearlessness and Nature of Current Suicidal Symptoms  Regarding nature of current suicidal symptoms, two concepts are important. The first is what we’ve termed Resolved Plans & Preparation (Developed Plan for Suicide, Sense of Courage & Competence to Commit Suicide, Opportunity, Intensity/Duration of Ideation).

117 Resolved Plans & Preparations  This symptom cluster includes –Vivid, detailed, long-lasting ideas about suicide –A sense of competence about suicide –A sense of fearlessness about suicide. –Well-developed plans Dangerous set of symptoms

118 Toward a Risk Assessment Framework  The other concept is what we’ve termed Suicidal Desire (Desire for Death, Frequency of Ideas and so on).  Both of these concepts represent serious things, but relatively speaking, the Resolved Plans & Preparation symptoms are more dangerous than the Suicidal Desire & Ideation factor.

119 Desire for Death  This symptom cluster includes –Vague and fleeting ideas about suicide –Statements like “would be better off dead.” –No well-developed plans Still worrisome set of symptoms, but RELATIVELY less dangerous.

120 Toward a Risk Assessment Framework The idea of the Risk Assessment Framework is that Other Risk Factors (e.g., Substance Abuse, Marked Impulsivity, Personality Disorder, others discussed above) Are Interpreted In Light of Two Main Areas Assessment (again, two main areas are History of Previous Attempt/Fearlessness and Nature of Current Suicidal Symptoms). This relieves somewhat the “laundry list” problem.

121 The Framework NOTE: “Other significant finding” means the list of suicide risk factors, things like severe recent negative life events, marked hopelessness, deteriorating health, loneliness, and so on. “Moderate Risk” refers to risk categories, such as None, Mild-Moderate, Severe, and Extreme. A multiple attempter with one other significant finding would be in the mild-moderate category; a multiple attempter with two other significant findings would be in the severe category; a multiple attempter with three or more other significant findings would be in the extreme category.

122 The Framework Multiple Attempter/Fearless? YesNo Any Other Significant Finding = AT LEAST Moderate Risk Elevated on Resolved Plans & Preparation? Yes No Elevated on Suicidal Desire & Ideation Yes No Low Risk Any Other Significant Finding = AT LEAST Moderate Risk Two or More Other Significant Findings = AT LEAST Moderate Risk

123 The Framework  Miscellaneous considerations can be used for people who are on the “edges” of categories (social support; religiosity).  Framework has to be used together with common sense.  The framework appears to be general across populations, with minor amendments as needed.

124 More on Risk Categories  The whole point of risk categories is to facilitate clinical decision-making.  If risk category is None: no action necessary, except determination to monitor risk in case it does increase (regular progress note to this effect is good practice).

125 More on Risk Categories  The coping card simply involves the development of a straightforward crisis plan that can be written down on the back of a business card, a 3 x 5 index card, or a sheet of paper. An example would be “When I’m upset and thinking of suicide, I’ll take the following steps:

126 More on Risk Categories  The coping card (cont).: 1) use what I’ve learned in therapy to try to identify what is upsetting me; 2) write down and review some reasonable, non- suicidal responses to what is bothering me; 3) try to do things that, in the past, have made me feel better (e.g., talking to, music, exercise, etc.); 4) if the suicidal thoughts continue and get specific, or I find myself preparing for suicide, I’ll call the emergency call person at (phone number; xxx-xxxx) or TALK; 5) if I feel that I cannot control my suicidal behavior, I’ll go to the emergency room or call 911.”

127 More on Risk Categories  If risk category is Severe: actions are similar to those for Mild-Moderate, but “stepped” up (e.g., do most or all of these), and voluntary hospitalization is discussed. Again, documentation in progress notes of risk category and attendant actions is necessary.  If risk category is Extreme: Hospitalization is enacted.  Documentation: Just do it every time.

128 No Suicide Contracts  What about no suicide contracts? Agreement to follow “coping card” may be better, because it tells people what to do instead of what not to do.  In one study, 41% of clinicians using contracts had patients die by suicide or severely attempt while on contract (Kroll, 2000, Am. J. Psychiat.).

129 Previous Treatment Research The controlled studies on psychotherapy converge on the finding that techniques involving CBT and problem-solving are safe, effective, and indicated.

130 Setting the foundation for treatment - Informed consent: confidentiality as balanced by safety; commitment to treatment – revisit as needed using motivational interviewing techniques.

131 Some Points about Therapeutic Relationship  a) explain that therapy relationship is a real relationship, and that suicidality is often interpersonally triggered in real relationships (e.g., perceived rejection) – discussing this openly will be important; b) expect to be provoked; c) consider tendency for “help negation” (Rudd, Joiner, & Rajab, 1995).

132 An empirically validated treatment for resolving suicidal behavior (cont.)  “Assume a virtue if you have it not, for use can almost change the stamp of nature.” - From Shakespeare’s Hamlet

133 An empirically validated treatment for resolving suicidal behavior (book by Rudd, Joiner, & Rajab, 2000)  Module/Session “1”: Main goals are to establish risk category (using techniques described earlier), to diagnose on Axis I and II (recall material on this described earlier), provide diagnostic feedback, and to diffuse crisis and lessen most troubling symptom or two.

134 An empirically validated treatment for resolving suicidal behavior (cont.)  Session 1 (continued): How to give standardized diagnostic feedback  Basic Steps:  1)Introduce your agenda of providing diagnostic feedback  2)Verbally reflect the main symptoms they have reported  3)Tell them the name for the disorder they are experiencing, and provide information about that disorder  4)Assure them that we know a lot about treatment for the disorder  5)Advise them to guard against misinformation regarding the diagnosis  6)Answer any diagnostic questions that they have

135 An empirically validated treatment for resolving suicidal behavior (cont)  "(step 1) Now that I have a sense of what has brought you here for treatment, I want to discuss your diagnosis. (step 2) You told me that recently you've been experiencing these symptoms, ____ and ____, and that you've been feeling ____ and ____. These symptoms and feelings cluster together into a syndrome. (step 3) There's a name for the syndrome that you've described, and it's called _____. This syndrome typically consists of symptoms like ___ and ____. People with this disorder typically feel like _____ [use the DSM for support during step 3. You may include additional information about course of the disorder if you desire].

136 An empirically validated treatment for resolving suicidal behavior (cont.)  We know a lot about this syndrome, both scientifically and clinically. (step 4) We also know a lot about how to treat this disorder effectively. (step 5) There is a lot of information available about this disorder. However, I'd like to caution you that much of the information you will find about this disorder (online, from a friend, or in a bookstore) may be incorrect. However, at this clinic, we know a lot about your syndrome, and I will be happy to give you as much information as you desire and help you to find good sources of information about the disorder. (step 6) Do you have any questions about your diagnosis?"

137 An empirically validated treatment for resolving suicidal behavior (cont.)  Session 1 (continued): Crisis resolution can be accomplished by plugging the crisis into the coping card, described earlier. Coping card also gives plan for what to do if suicidality escalates.

138 An empirically validated treatment for resolving suicidal behavior (cont.)  Session 1 (continued): Symptoms can be targeted by having patients list the several feelings, thoughts, experiences, etc., that are most troubling to them, and rating each on a scale of 1 to 10 (with 10 most severe).

139 An empirically validated treatment for resolving suicidal behavior (cont.)  Session 1 (continued): For the top two or so symptoms (e.g., sadness, loneliness, sleep problems, anxiety), recommend simple, straightforward things that “won’t necessarily solve the whole problem, but will take the edge off; this will make you more comfortable so that later, we’ll be able to get to the root problem.”

140 An empirically validated treatment for resolving suicidal behavior (cont.)  Session 1 (continued): Commonly recommended things are behavioral activation/pleasant activities (listening to music, seeing movies, taking a walk, calling a friend), sleep hygiene, exercise, and elicitation of social support (Linehan lists > 200).

141 An empirically validated treatment for resolving suicidal behavior (cont.)  Sessions 2 & 3: Assess risk; review treatment log; review use of coping card. Main additional tasks are introduction of the Suicidal Thought Record and a description of the suicidal cycle.

142 An empirically validated treatment for resolving suicidal behavior (cont.)  Sessions 2 & 3 (continued): The Suicidal Thought Record is a way for patients to learn on their own about the suicidal cycle; i.e., about the interconnections between situations, what they’re thinking and feeling, and their suicidal behavior. Filling one or more out in session, and discussing then and there, is a quick way to impart the basics.

143 An empirically validated treatment for resolving suicidal behavior (cont.)  Sessions 4 and beyond: The rest of the work involves in-session and between-week –problem-solving; –cognitive restructuring; –and emotion regulation work all on the material from the Suicidal Thought Record.

144 An empirically validated treatment for resolving suicidal behavior (cont.) So, week in and week out, problem-solving, cognitive, and emotion regulation techniques are taught, applied to real life situations, applied to the therapeutic relationship, written about in the treatment log, and so forth.

145 An empirically validated treatment for resolving suicidal behavior (cont.)  “Assume a virtue if you have it not, for use can almost change the stamp of nature.” - From Shakespeare’s Hamlet

146 An empirically validated treatment for resolving suicidal behavior (cont.)  Sessions 4 and beyond (continued): The problem-solving technique essentially amounts to the coping card, referred to already.

147 An empirically validated treatment for resolving suicidal behavior (cont.)  Sessions 4 and beyond (cont.): For emotion regulation, problem-solving and cognitive approaches are emotion regulation techniques. Also, mood graphs are useful ways to teach people about how “bad feelings do not last forever.” Just by waiting, bad feelings tend to lessen (and they lessen even more quickly when they are addressed with problem-solving and cognitive techniques). “Bad feelings do not last and are changeable” becomes a mantra of therapy.

148 An empirically validated treatment for resolving suicidal behavior (cont.)  Sessions 4 and beyond (continued): Cognitive restructuring, The ICARE approach:  I for Identify – identify the negative thought.  C for Connect – connect the negative thought to the type of distortion it represents.  A for Assess – assess the thought, asking “what objective evidence supports this thought?” “What evidence refutes it?”

149 An empirically validated treatment for resolving suicidal behavior (cont.)  Sessions 4 and beyond (continued): Cognitive restructuring, The ICARE approach:  R for Restating – restate the thought in more reasonable terms; often this involves removing the cognitive distortion from “C for Connect.”  E for Execute – act as if the restated belief were true.

150 An empirically validated treatment for resolving suicidal behavior (cont.)  “Assume a virtue if you have it not, for use can almost change the stamp of nature.” - From Shakespeare’s Hamlet

151 Pulling It All Together - Toward an algorithm for choosing and timing treatments

152 Pulling It All Together - If suicidality is primary, essentially regardless of what’s going on on Axes I/II, then a treatment focused on suicidality is indicated, for the simple reasons of decreasing dangerousness, and the fact that progress with regard to suicidality (e.g., using problem-solving, emotion regulation, cognitive restructuring) is very likely to benefit whatever else is going on diagnostically (e.g., mood or anxiety disorder; personality disorder).

153 Pulling It All Together - If suicidality is primary (cont.): Once suicidality has receded, re- evaluate and then target remaining symptoms, using the logic described next.

154 Pulling It All Together If suicidality is secondary to Axis I or II disorder, then a treatment focused on suicidality is probably not indicated (but remains a defensible choice, because of dangerousness, and the fact that progress with problem-solving, emotion regulation, cognitive restructuring, etc. will benefit Axis I and II disorders). Might be better to regularly monitor to suicidality, and to institute diagnosis-based treatments, and once targeted disorders have receded, re-evaluate and then target any remaining suicidal symptoms, using treatments focused on suicidality.

155 Thank You!


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